In recent years medical and prescription claim processing has become a highly automated process. Today, thousands of claims are electronically transmitted daily from healthcare service providers (“providers”) to insurance companies and other payers (collectively, “payers”). These claims are processed and stored in near-real time, thereby expediting the process of paying healthcare service providers for their services.
Unfortunately, however, many electronically-transmitted claims are rejected by payers because the claims' contents are in error. In fact, payers typically reject almost 20 percent of electronically transmitted claims because of errors in the claims. Claim errors include insufficient information, improper information, and/or conflicting information. This problem is particularly challenging due to the wide variety of payers and medical and pharmaceutical plans, each of which often has its own standards dictating the content of an electronically-transmitted claim.
At a minimum, reducing the number of claim rejections would reduce costs associated with claim communication and processing. Additionally, reducing the number of claim rejections will increase the speed at which claims are processed because claims will not need to be submitted multiple times to correct errors. Therefore, what is needed is an automated system and method for automatically reviewing the contents of a claim transmitted to a payer, and for identifying problems with the claim before it is transmitted to the payer. Preferably, such a system and method would also automatically edit the claim such that it complies with payer requirements.